A 79 years old male patient was referred to our unit for laparoscopic resection of a small malignant right-sided colonic lesion identified during a previous colonoscopy.
A repeat full colonoscopy with intubation of the terminal ileum was performed. During withdrawal phase a 2.5 centimetres non-polypoid lesion was identified at the level of the hepatic flexure.
Under magnification the lesion has an obvious malignant appearance and therefore is not resectable endoscopically. A smaller benign subpedunculated polyp was identified distally.
To facilitate a laparoscopic resection with safe surgical margins tattooing was performed using tri-quadrant non-spilling technique.
The endoscope is withdrawn and the tattoo site is selected 4 to 5 cm distally with the lesion still in view. The injection needle is inserted in the submucosal plane and a 1 millilitre saline bleb is raised.
Without changing the position of the needle a 1.5 millilitres of permanent endoscopy marker is injected within the saline bleb. The procedure is repeated in another 2 quadrants at 120 degrees to each other. In between injections the residual ink should be flushed from the needle so the initial bleb is raised with saline at each tattoo site.
The final endoscopic appearance clearly demonstrates the visible tattoos with the tumour seen in the same frame confirming adequate distal placement of the tattoos.
The following views were taken during laparoscopic resection. One could note the large amount of visceral fat visible as bulky fatty appendix epiploicae, greater omentum and short fatty mesocolon. Only one tattoo is clearly visible at the level of the antimesenteric border as a dark blue marker. The pre-injection with saline allows a highly visible tattoo to be seen with no spillage inside the peritoneal cavity.
To understand the importance of tattooing in three quadrants I invite you to compare these two frames side by side. Despite demonstrating clearly three highly visible endoscopic tattoos only one could be identified intraoperatively during laparoscopic resection. The examination of the resected specimen confirmed that indeed two out of three tattoos were completely obscured by fat.
The final histopathological report confirms a pT3N0M0 moderately differentiated adenocarcinoma of the hepatic flexure with all 15 nodes free of tumour.
Marius Paraoan, MD, Wrightington, Wigan and Leigh NHS Foundation Trust